Cycle 1
Health 2025-01-16 · Fire 2025-01-16
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
La Mesa, CA
Country Manor La Mesa Healthcare Center
4-star overall rating with 4-star inspections with 10 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
5696 Lake Murray Blvd, La Mesa, CA
(619) 460-7871
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cambridge Healthcare Services
Operator or chain grouping
Approved since
1968-03-22
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
32 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.52
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.13
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.39
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.04
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.70
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,570
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.91
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 22.41% · Performance 23.11% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.03% · Performance 7.95% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.16
Baseline 31.32% · Performance 42.57% · Measure score 5.16 · Achievement 5.16 · Improvement 0
Adjusted total nurse staffing
2.8
Baseline 3.49 hours · Performance 3.87 hours · Measure score 2.8 · Achievement 2.8 · Improvement 1.17
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.61% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 190 · Observed rate 7.89% · Lower 95% interval 7.13% |
| Discharge to community | 45.03% |
50.57%
5.5 pts worse
|
No Different than the National Rate · Eligible stays 195 · Observed rate 40% · Lower 95% interval 37.88% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.46% |
95.27%
4.2 pts better
|
Numerator 185 · Denominator 186 |
| Falls with major injury | 0.54% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 186 |
| Discharge self-care score | 53.06% |
53.69%
0.6 pts worse
|
Numerator 52 · Denominator 98 |
| Discharge mobility score | 39.8% |
50.94%
11.1 pts worse
|
Numerator 39 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 186 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.95% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 8.7% · Lower 95% interval 5.11% |
| Staff COVID-19 vaccination coverage | 21.09% |
8.2%
12.9 pts better
|
Numerator 31 · Denominator 147 |
| Staff flu vaccination coverage | 49.7% |
42%
7.7 pts better
|
Numerator 82 · Denominator 165 |
| Discharge function score | 54.08% |
56.45%
2.4 pts worse
|
Numerator 53 · Denominator 98 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 45 · Denominator 45 |
| Transfer of health information to patient | 98.97% |
96.28%
2.7 pts better
|
Numerator 96 · Denominator 97 |
| Resident COVID-19 vaccinations up to date | 39.56% |
25.2%
14.4 pts better
|
Numerator 36 · Denominator 91 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
2.3
0.2 pts better
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.6
0.1 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
1.6%
0.1 pts worse
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.6% · Q3 1.4% · Q4 1.5% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.6% |
6.8%
4.8 pts worse
|
11.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 11.6% · Q3 12.1% · Q4 6.8% · 4Q avg 11.6% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
4.1%
1.3 pts worse
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 6.2% · Q3 8.8% · Q4 3.6% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.5% |
13.7%
3.2 pts better
|
19.6%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 8.6% · Q3 12.9% · Q4 13.3% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
14.2%
2.8 pts better
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 8.6% · Q3 11.4% · Q4 19.4% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.7% |
11.0%
5.3 pts better
|
16.3%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 9.4% · Q3 11.9% · Q4 0.0% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
10.7%
2 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 19.7% · Q3 3.6% · Q4 3.7% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.6% |
1.2%
2.4 pts worse
|
1.7%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 4.2% · Q3 4.4% · Q4 4.8% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 6.3% |
10.9%
4.6 pts better
|
19.8%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 6.3% · Q3 10.7% · Q4 1.6% · 4Q avg 6.3% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
4.7%
3.2 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.3% · Q3 1.1% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
11.2%
1.6 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 9.5% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.5%
1.5 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 5.1% · Q4 2.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
93.2%
5 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.9% |
23.2%
3.7 pts worse
|
23.9%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 27.0% · Expected 24.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-11-19 · Fire 2021-11-19
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2019-09-20 · Fire 2019-09-20
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-16
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-02-05
E · Potential for more than minimal harm
2025-01-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-05
E · Potential for more than minimal harm
2025-01-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-05
E · Potential for more than minimal harm
2025-01-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-05
D · Potential for more than minimal harm
2025-01-16
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2025-02-05
C · Minimal harm
2025-01-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-05
D · Potential for more than minimal harm
2021-11-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-16
D · Potential for more than minimal harm
2021-11-19
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-12-16
D · Potential for more than minimal harm
2019-09-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-20
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-20
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-01-17
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-01-22
D · Potential for more than minimal harm
2025-01-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-22
D · Potential for more than minimal harm
2025-01-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-22
E · Potential for more than minimal harm
2025-01-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-03
E · Potential for more than minimal harm
2025-01-16
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-16
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-16
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-16
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-16
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-02-03
D · Potential for more than minimal harm
2025-01-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-03
D · Potential for more than minimal harm
2024-09-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-10-01
D · Potential for more than minimal harm
2024-09-23
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-10-01
F · Potential for more than minimal harm
2021-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-22
E · Potential for more than minimal harm
2021-11-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-12-22
D · Potential for more than minimal harm
2021-11-19
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-12-22
D · Potential for more than minimal harm
2019-09-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-09-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-09-20
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-11-20
D · Potential for more than minimal harm
2019-09-20
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-11-20
Penalties and ownership
What sits behind the stars
Ownership
Ag Facilities Operations, LLC
5% Or Greater Direct Ownership Interest · Organization
Abesamis, Wilfredo
Operational/Managerial Control · Individual
Bh Alliance
5% Or Greater Indirect Ownership Interest · Organization
Butenko, Julie
Operational/Managerial Control · Individual
Cambridge Healthcare Services LLC
Operational/Managerial Control · Organization
Capela, Heidi
Operational/Managerial Control · Individual
Hassell, Lance
Operational/Managerial Control · Individual
Ira E Smedra Living Trust
5% Or Greater Indirect Ownership Interest · Organization
Lutz, Linda
Operational/Managerial Control · Individual
Mey, Somrutai
Operational/Managerial Control · Individual
Ramos, Rhodora
Operational/Managerial Control · Individual
Salazar, Paulina
Operational/Managerial Control · Individual
Smedra, Ira
5% Or Greater Indirect Ownership Interest · Individual
Vidales, Miguel
Operational/Managerial Control · Individual
Win Win Enterprises, LLC
5% Or Greater Indirect Ownership Interest · Organization
Wintner, Jacob
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Arbor Hills Nursing Center
La Mesa, CA
3-star overall rating with 2-star inspections with $12,831 in total fines with 19 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Parkway Hills Nursing & Rehabilitation
La Mesa, CA
3-star overall rating with 3-star inspections with 14 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Grossmont Post Acute Care
La Mesa, CA
5-star overall rating with 4-star inspections with $11,466 in total fines with 7 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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